I read with interest the article by Skinner et al1 assessing whether case management of frequent attenders to an urban emergency department reduces frequency of subsequent attendances. The case for multidisciplinary management of frequent attenders is well made, and the reported practice of case review and implementation of care plans is highly commendable.

However, a possible considerable limitation of this study is not fully elucidated in the authors’ discussion. Although mention is made that the reduction seen in attendances by frequent attenders after the case review “may be due to the natural ebb and flow in the presentations of these patients”, …